Written confirmation form for third party authorisation

Section A Applicants details

Section B Third party details
W: www.nmc-uk.org T:0207 333 9333 (!! 207 333 9333 when ca""ing from outside the #$%
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Full name (((((((((((((((((((((((((( NMC Pin or PRN ((((((((((((((((((((
) here*y authorise the +ursing , -idwifery .ounci" to discuss with the third party
mentioned *e"ow:
)nformation concerning my current app"ication to the register
)nformation concerning my current registration
/ignature
0ate
)s the third party an indi1idua" or company2
.ompany yes if yes please skip to section C on page 2
)ndi1idua" yes if yes please fill out the information below
3u"" name of third party
0ate of *irth
4ddress
5ccupation
6e"ationship to nurse or midwife
Please now go to Section D on page 2
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Written confirmation form for third party authorisation
Applicants details
Section C Company third party details
Section Password
&"ease return this form to: Nursin# $ Midwifery Council% Re#istrations% &' Portland
Place% (ondon% )*B *P+,
4"ternati1e"y= you can emai" a scanned copy to thirdpartyen>uiries?nmc-uk.org or fa@
to 020 7A7' B300.
&"ease remem*er your form must *e signed and dated in /ection 4.
W: www.nmc-uk.org T:0207 333 9333 (!! 207 333 9333 when ca""ing from outside the #$%
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.ompany or agency name
+ame(s% of your nominated indi1idua"(s%
3u"" address of the company or agency
)ndi1idua"(s% position within the company
Please now go to Section D
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The nurse or midwife and the third party must agree on a password which wi"" *e
used *y the third party in a"" communications with the +ursing and -idwifery .ounci"
+-. '23!
Full name (((((((((((((((((((((((((( NMC Pin or PRN ((((((((((((((((((((